Obesity is an abnormal accumulation of fat that poses a high health risk. A well-known scale used to assess whether a person is obese or overweight is the body mass index or BMI scale. According to the World Health Organization (WHO), more than 1 billion people worldwide are obese including 33.7% of the population in Saudi Arabia [1]. Obesity is associated with a higher risk of comorbidities such as type 2 diabetes mellitus, hypertension, gallbladder disease, cardiovascular disease, dyslipidemia and obstructive sleep apnea [2].   Type 2 Diabetes Mellitus (T2DM) is a growing worldwide health concern, strongly associated with the increasing rates of obesity. People with T2DM face a significant risk of developing microvascular complications, such as retinopathy, nephropathy and neuropathy, as well as macrovascular issues, including cardiovascular diseases. These risks are primarily due to elevated blood sugar levels and various elements of the insulin resistance (metabolic) syndrome [3].   Bariatric surgery results in significant and long-lasting weight loss. Approximately 30% of individuals who undergo this surgery have type 2 diabetes with a large percentage achieving remission following the procedure. For those undergoing bypass procedures, diabetes resolution occurs in 84% to 98% of cases, whereas for restrictive procedures, the resolution rates range from 48-68% [4]. Recent studies have demonstrated that weight loss surgery can lead to a significant improvement in weight management, blood sugar control and the resolution of type 2 diabetes, as well as a reduction in cardiovascular complications and mortality rates [5].   Bariatric surgery is primarily indicated for patients with severe obesity, especially when it contributes to various health complications, including cardiovascular disease (CVD). It is considered when obesity significantly impacts health and when patients cannot achieve sustained weight loss through nonsurgical methods. This procedure aims to facilitate weight loss, which can help reverse or improve obesity-related health conditions [2].   Bariatric surgery is associated with immediate and long-term complications. Early complications include bleeding is the most common immediate, anastomotic leaks from surgical connection. Pulmonary embolism and deep venous thrombosis, respiratory complications, nausea and vomiting and dehydration. Late complications include nutritional deficiencies, anemia, dumping syndrome, gallstones, bowel obstruction, strictures or ulcers, weight regain, hypoglycemia and psychological disorders such as depression and eating disorders. The risk and type of complications vary depending on the surgical procedure (e.g., sleeve gastrectomy, gastric bypass, adjustable gastric banding) and patient factors such as comorbidities and adherence to follow-up care [6].   Around 27,000 bariatric surgeries are performed each year in Saudi Arabia [7]. Although bariatric surgery is becoming increasingly popular in Saudi Arabia, misconceptions and concerns about its eligibility criteria, safety, benefits, social stigma and financial barriers persist [8]. This study aims to evaluate the awareness and knowledge of the benefits of bariatric surgery for diabetes patients in the Northern Borders region of Saudi Arabia. It seeks to address the existing gap in understanding the advantages of this procedure. The primary goal is to assess how well the benefits and impacts of this surgery on diabetes management are understood in the region.   Aim of the Study To evaluate the level of awareness regarding the benefits of bariatric surgery for patients with T2DM.   Study Objectives The specific objectives are:   To compare the level of awareness of the benefits of bariatric surgery for diabetic patients in the Northern Border region between diabetic and non-diabetic participants To assess awareness about potential indications for bariatric surgery To explore obesity-related complications experienced by patients

Study Design, Setting and Participants This cross-sectional study was conducted between December 2023 and February 2024 in the Northern Border Region of Saudi Arabia. The study’s inclusion criteria were adults aged 18-65 years residing in the Northern Border Region. The exclusion criteria involved people younger than 18 or older than 65 years and those who submitted incomplete questionnaires (>50% missing items). Sample Size The minimal sample size was calculated using the following equation: where, Z1-α/2 is the standard normal variate at 5% type 1 error (p<0.05); it is 1.96. P the expected proportion and d the absolute error (0.05). Since no previous studies had been conducted in the Northern border region, the expected proportion of outcome will be considered 50% to maximize the sample size. Accounting for a 10% non-response rate, the calculated sample size was 422 (384+ (384x10%). Data Collection Tools A self-administered questionnaire was adopted, with permission, from a recent study conducted in the Makkah region [9]. The questionnaire was distributed electronically via Google Forms and all collected data were kept secure and confidential. The survey included sections on sociodemographic characteristics, awareness of bariatric surgery and obesity in relation to diabetes mellitus, knowledge of potential complications of bariatric surgery and perceived outcomes of bariatric surgery in patients with T2DM. Ethical Considerations This study was conducted in accordance with the Declaration of Helsinki. Approval of the study was obtained from the local bioethical committee of Northern Border University (No. 7/24/H).   Before accessing the electronic questionnaire, participants were provided with information about the study’s purpose, procedures and potential benefits. They were informed participation was voluntary and they could discontinue the questionnaire at any time without penalty. No personally identifiable information was collected and all responses were kept confidential. Proceeding to complete and submit the electronic questionnaire was considered as providing informed consent.   Statistical Analysis Collected data were summarized in terms of Mean±Standard Deviation (SD) and range for quantitative data and the frequency and percentage for qualitative data. The Shapiro-Wilk W test was used to examine the distribution of numerical data. The Mann-Whitney test (Z), Chi-squared test (X2) and the Fisher Exact test (FET) were used for comparisons between the different study groups, as appropriate. Two-tailed p<0.05 was considered statistically significant. The collected data were entered, described and analyzed using the computerized statistical package STATA/SE version 11.2 for Windows (STATA Corporation, College Station, Texas) and MS Excel.

A total of 486 adults (>18 years old) participated in the study. Of these 58 (11.93%) had type-2 diabetes mellitus (T2DM) for an average duration of 8.12 (±7.32) years and 86.21% of them reported adherence to diabetes medications. Table 1 shows differences in sociodemographic characteristics between subjects with T2DM and those without.   Table 1: Sociodemographic Characteristics of the Studied Subjects with Diabetes Type 2 and Those Without in Arar, Saudi Arabia Variable No T2DM type 2 (n. = 428; 88.07%) T2DM (n. = 58; 11.93%) Total (n. = 486) Test p-value n. % n. % n. % Gender Female 338 78.97 40 68.97 378 77.78 χ2 = 2.96 0.08 Male 90 21.03 18 31.03 108 22.22 Age (year) Mean±SD 31.05±10.99 45.95±11.46 32.83±12.05 Z = 7.87 <0.001 Range 18-62 22-65 18-65 <20 48 11.21 0 0.00 48 9.88 χ2 = 79.47.47 <0.001 20 to <30 191 44.63 6 10.34 197 40.53 30 to <40 59 13.79 8 13.79 67 13.79 40 to <50 103 24.07 21 36.21 124 25.51 50-65 27 6.31 23 39.66 50 10.29 Nationality Saudi 424 99.07 57 98.28 481 98.97 FET 0.47 Non-Saudi 4 0.93 1 1.72 5 1.03 Educational level A university degree 298 69.63 38 65.52 336 69.14 FET 0.12 High school/ diploma 121 28.27 16 27.59 137 28.19 No educational certificate 9 2.10 4 6.90 13 2.67 Family history of diabetes First degree relatives 185 43.22 40 68.97 225 46.30 χ2 = 17.16 <0.001 Second degree relatives 92 21.50 12 20.69 104 21.40 Nothing 151 35.28 6 10.34 157 32.30 Family history of or a family member who is overweight/obese Yes 228 53.27 36 62.07 264 54.32 χ2 = 1.59 0.21 No 200 46.73 22 37.93 222 45.68 Family history or family member who had a bariatric surgery Yes 162 37.85 25 43.10 187 38.48 χ2 = 0.59 0.44 No 266 62.15 33 56.90 299 61.52 BMI (kg/m2) Mean±SD 26.34±6.14 28.46±5.06 26.59±6.06 Z = 3.02 0.002 Range 12.89-69.53 18.36-42.97 12.89-69.53 <18.5 29 6.78 1 1.72 30 6.17 FET 0.06 18.5-24.99 163 38.08 14 24.14 177 36.42 25-29.99 132 30.84 22 37.93 154 31.69 30-34.99 74 17.29 14 24.14 88 18.11 ≥35 30 7.01 7 12.07 37 7.61 Ever had a bariatric surgery Yes 19 4.44 4 6.90 23 4.73 FET 0.34 No 409 95.56 54 93.10 463 95.27 χ2: The Chi-square test, FET: Fisher Exact test, Z: The Mann-Whitney test, Statistical significance was considered at p<0.05   As expected, diabetic subjects were significantly older (p<0.001), more likely to have had a family history of diabetes in the first-degree relatives (p<0.001) and had a higher BMI than non-diabetics (p = 0.002).   Table 2 shows that the majority of participants (76.75%) have seen some messages raising awareness about obesity and diabetes. About 13.79% of subjects with T2DM thought that obesity did not affect the level of insulin sensitivity compared to 4.44% of non-diabetics (p = 0.02). More than half of the participants did not know what was necessary for a person to undergo bariatric surgery and had heard about the complications of bariatric surgery. The majority of participants believed that obesity was an incurable disease. Even more diabetics did not agree that losing excess weight helps control diabetes and reduce its complications (p = 0.01).   Table 2: Awareness About Bariatric Surgery and Obesity Among Diabetic and Non-Diabetic Adults in Arar, Saudi Arabia Variable No T2DM (n. = 428; 88.07%) T2DM (n. = 58; 11.93%) Total (n. = 486) Test p-value n. % n. % n. % Have you ever seen awareness messages about obesity and diabetes via email, SMS or social media? Yes 328 76.64 45 77.59 373 76.75 χ2 = 0.02 0.87 No 100 23.36 13 22.41 113 23.25 Does obesity affect the level of insulin sensitivity? Yes 279 65.19 35 60.34 314 64.61 FET 0.02 No 19 4.44 8 13.79 27 5.56 I do not know 130 30.37 15 25.86 145 29.84 Do you know what is necessary for a person to perform bariatric surgery? Yes 204 47.66 24 41.38 228 46.91 χ2 = 0.81 0.37 No 224 52.34 34 58.62 258 53.09 Have you heard about the complications of bariatric surgery? Yes 295 68.93 34 58.62 329 67.70 χ2 = 2.48 0.11 No 133 31.07 24 41.38 157 32.30 Obesity is an incurable disease Yes 376 87.85 46 79.31 422 86.83 FET 0.08 No 14 3.27 5 8.62 19 3.91 I do not know 38 8.88 7 12.07 45 9.26 Reducing excess weight helps control diabetes and limits its complications Yes 359 83.88 48 82.76 407 83.74 FET 0.01 No 11 2.57 6 10.34 17 3.50 I do not know 58 13.55 4 6.90 62 12.76 χ2: The Chi-square test, FET: Fisher Exact test, Statistical significance was considered at p<0.05   Figure 1 shows that the most frequently reported reasons for bariatric surgery among subjects with T2DM were a BMI>35 with the presence of a chronic disease (25.86%), a BMI>40 (22.41%) and beauty purposes (20.69%). As for non-diabetic subjects, the most common reasons were a BMI>40 and a BMI>35 with the presence of a chronic disease (28.27% and 27.1%, respectively). There were no significant differences in the reasons for bariatric surgery between diabetic and non-diabetic individuals (p = 0.38).     Figure 1: Comparisons of Reported Reasons for Bariatric Surgery Among the Studied Diabetic and Non-Diabetic Adults in Arar, Saudi Arabia   Figure 2 shows complications of bariatric surgery reported by subjects with T2DM and those without. Among those with T2DM, the most frequently reported complications were a lack of minerals and stomach leakage (60.34% and 46.55%, respectively). In non-diabetics, anemia and lack of minerals were the most commonly reported complications (47.43% and 45.79%, respectively). The proportion of subjects with T2DM who reported a lack of body minerals was significantly higher than the non-diabetics (χ2 = 4.34; p = 0.04).   Only 23 participants reported undergoing bariatric surgery, with four of them having T2DM and 19 being non-diabetic. Among the diabetic subjects, three had achieved normal blood glucose levels after the surgery, while two reported a reflux and one reported joint roughness. Among non-diabetics, eight reported reflux, four reported high blood pressure, two reported joint roughness, one reported high blood glucose and one reported sleep apnea after the bariatric surgery.     Figure 2: Comparisons of Bariatric Surgery Complications Reported by the Studied Diabetic and Non-Diabetic Adults in Arar, Saudi Arabia

Obesity is a chronic disorder; a person is said to be obese when their BMI is equal to or greater than 30 kg/m2. There are several treatment options available, one of the most effective treatments is Bariatric surgery. Bariatric surgery is a successful therapeutic option for long-term weight loss and the resolution of medical comorbidities associated with obesity, particularly type 2 diabetes [10].   This study aimed to assess the awareness and knowledge of the advantages of bariatric surgery and its effects on diabetic patients in the Northern border region of Saudi Arabia. A total of 486 adults were included in the study, with 77.78% being female and 22.22% male. The findings showed that 11.93% of the participants had type-2 diabetes and the majority of 86.21% reported adherence to diabetes medications. The prevalence of T2DM in our study is comparable to a recent national study in Saudi Arabia of 12% [11]. However, it is lower than the estimate from a systematic review, which reported a pooled prevalence of T2DM in Saudi Arabia of 16.4% (95% CI: 11.6-17.5). The high prevalence of T2DM in the Saudi population underscores a significant public health burden [12].   The overall prevalence of obesity (BMI ≥30 kg/m²) in the present study was 25.72%. Althumiri et al. [13] reported obesity levels across the 13 administrative regions of Saudi Arabia ranging from 14.3-29.4%. In agreement with these findings, a study conducted among Saudi individuals covered by private health insurance reported an obesity prevalence of 19.8% [11]. However, a higher prevalence of obesity (58.3%) in the Northern Border region was recorded by Alanazi et al. [14]. The prevalence observed in the current study falls within the nationally reported range and remains higher than many global estimates. This elevated burden of obesity in Saudi Arabia has been attributed to rapid lifestyle transitions, including reduced physical activity and a shift toward Westernized dietary patterns rich in fats and refined sugars. These findings highlight the urgent need for targeted public health interventions aimed at promoting healthy dietary habits and effective weight management strategies [15].   As expected, the diabetic patients were notably older, more likely to have a family history of diabetes in first-degree relatives and had a higher BMI than non-diabetics, these findings are similar to a study conducted in India in 2017 [16]. Also, Socioeconomic and biodemographic characteristics, including obesity, a positive family history of diabetes, marital status, higher socioeconomic status and a lower level of education, were found to be substantially linked to an increased risk of diabetes in the older adult population in West Bengal. Because excess body fat, particularly around the abdomen, induces insulin resistance, hinders glucose metabolism and upsets the hormone balance that controls blood sugar, obesity raises the risk of developing diabetes [17].   Results from a community-based survey that investigated the prevalence and risk factors for type 2 diabetes and pre-diabetes in adult Egyptians who had not yet received a diagnosis, revealed that, Age, physical inactivity and an increased waist circumference were all found to be significant predictors for type 2 diabetes [18].   Although 76.75% of the study participants had seen messages raising awareness about obesity and diabetes, a significant number of participants held the belief that obesity was an incurable disease. Additionally, a higher proportion of the diabetic participants disagreed that losing excess weight could help control diabetes and reduce its complications. Furthermore, 13.79% of patients with T2DM thought that obesity did not affect insulin sensitivity compared to 4.44% of non-diabetics. Meanwhile, a study conducted in Malaysia reported that adopting physical activity and making dietary modifications were essential in managing BMI, waist circumference and body lipids, ultimately leading to an enhanced glycemic control [19].   This study shows that the most compelling reasons for patients with T2DM to consider bariatric surgery were a BMI>35 with the presence of a chronic disease (25.86%), a BMI>40 (22.41%) and beauty purposes (20.69%). As for non-diabetic subjects, the most common reasons were a BMI>40 and a BMI>35 with the presence of a chronic disease (28.27% and 27.1%, respectively). A similar study reported that some of the most common reasons for undergoing bariatric surgery included a desire to improve medical conditions and to make daily life easier [20].   More than half of the participants were aware of the potential complications of bariatric surgery. Similarly, a study conducted in Saudi Arabia in 2024 reported that 81% of individuals were aware of the complications associated with sleeve gastrectomy [21]. This relatively high level of awareness regarding surgical risks may partly explain the low uptake of bariatric surgery among the study participants and their family members.   The cross-sectional design of this study provided a comprehensive snapshot of the current level of awareness and perceptions regarding obesity, diabetes and bariatric surgery. However, several limitations should be considered when interpreting the findings. The cross-sectional nature precludes the establishment of causal relationships and may be subject to inherent biases. Data collection through online Google Forms may have introduced selection bias, as individuals with limited access to or familiarity with digital technology could have been underrepresented. Moreover, diabetes status was self-reported rather than clinically verified, which may have led to misclassification due to recall bias or social desirability bias. The relatively small number of participants with T2DM, along with the low prevalence of bariatric surgery among respondents, further limits the statistical power and generalizability of subgroup comparisons. Future large-scale studies with clinically confirmed diagnoses are recommended to validate and expand upon these findings.

In conclusion, a large proportion of participants reported exposure to awareness messages about obesity and diabetes. However, important gaps in knowledge and misconceptions persist both among diabetic and non-diabetic individuals. More than one-third of participants did not recognize the impact of obesity on insulin sensitivity. Fewer than half were aware of the proper indications for bariatric surgery and a considerable proportion incorrectly believed that it is performed for cosmetic purposes. Although approximately two-thirds of participants were aware of potential complications of bariatric surgery, misconceptions regarding obesity itself were evident, as most participants perceived it as an incurable disease. Nevertheless, the majority acknowledged that weight reduction plays a significant role in controlling diabetes and limiting its complications. These findings highlight the need for targeted educational interventions to address misconceptions and improve understanding of obesity and bariatric surgery as a treatment option that could contribute to better obesity management and improved health outcomes for those with type 2 diabetes.